Feasibility of a laparoscopic approach for generalized peritonitis from perforated appendicitis in children

The Risk of Adhesive Bowel Obstruction in Children With Appendicitis: A Systematic Review

OBJECTIVE

Complicated appendicitis is associated with a higher risk of postoperative complications, including adhesive bowel obstruction. The aim of this meta-analysis is to investigate the difference in rates of postoperative bowel obstruction in paediatric patients with complicated versus simple appendicitis and whether this is influenced by the surgical approach.

METHODS

A systematic literature search following PRISMA guidelines was conducted using MEDLINE, Embase and Cochrane Library for studies that analysed incidence of adhesive bowel obstruction in paediatric patients after appendicectomy. Studies from 1998 to 2022 were included in analysis. The study protocol was registered on PROSPERO (ID CRD42022309769).

RESULTS

Pooled analysis of 6 studies with low risk of bias and adequate follow up periods, considering 58,962 cases of appendicectomy, revealed complex appendicitis was associated with a near two-fold increase in incidence of SBO (pooled odds ratio 2.02 (95% CI 1.35-2.69)). Interestingly, a similar pooled analysis of 10 studies, considering 62,433 cases of appendicectomy, revealed no significant difference between open and laparoscopic management of complex appendicitis (pooled odds ratio 0.93 (95% CI 0.24 to 1.62)).

CONCLUSION

Complex appendicitis is associated with a two-fold increase in the rates of adhesive bowel obstruction. Whilst there are cosmetic advantages of a laparoscopic approach, surgical expertise should be favoured in decision making relating to surgical approach (laparoscopic versus open) as the evidence for a laparoscopic approach reducing risks of adhesive bowel obstruction is not convincing.

LEVEL OF EVIDENCE

Level II.

Laparoscopic appendectomy: Effectiveness in children with generalized and advanced generalized peritonitis cases

Laparoscopic appendectomy is one of the most common surgical procedures in treating pediatric appendicitis. This study aimed to investigate the efficacy of laparoscopic surgery in cases complicated with advanced generalized peritonitis in the pediatric population. The study retrospectively reviewed 55 cases of children who underwent laparoscopic appendectomies. The cases were classified as uncomplicated, complicated, or advanced generalized peritonitis. Laboratory results, diagnostic algorithms, surgical techniques, and complications were investigated. Twenty-four of the cases were boys and 31 were girls. Mean age was 11.3 ± 3 years. Twenty of the cases (36%) were uncomplicated and 35 (64%) were complicated. Nine of the complicated cases presented advanced generalized peritonitis and were additionally classified as "another special group". Mean leukocyte count and C-reactive protein levels were measured respectively as 22.49 ± 12 x 10⁹ /L and 120.5 ± 99 mg/L in complicated cases and as 17.06 ± 10 x 10⁹ and 52.37 ± 69 mg/L in uncomplicated cases. All advanced generalized peritonitis cases had presented to the hospital with intestinal obstruction and had diffuse abdominal rigidity on physical exam. None of the cases had any complications in the intraoperative or early postoperative period. Infection complications (namely, intra-abdominal abscesses and surgical site infections) were observed in four cases (7%) in the postoperative period. Mean length of hospital stay was 5.62 ± 2.6 days and 3.95 ± 1 days in complicated and uncomplicated cases, respectively. Mean length of stay in advanced generalized peritonitis cases was 8.33 ± 2 days. It was observed that laparoscopic appendectomy might be the first choice of treatment option in cases complicated with advanced generalized peritonitis.

Laparoscopic versus open appendicectomy for complicated appendicitis in children: A systematic review and meta-analysis

BACKGROUND

Laparoscopic appendectomy (LA) is the preferred approach in uncomplicated appendicitis. However, in patients with complicated appendicitis (CA), the best approach is still unclear though laparoscopy is being increasingly preferred over open appendicectomy (OA) nowadays.

AIM

To comprehensively review the current literature and compare the associations of LA and OA concerning various postoperative outcomes in order to determine the best approach for children with CA.

METHODS

The PRISMA guidelines were adhered to and an electronic database search was extensively performed. Data analysis, including subgroup analysis of randomized-control trials, was performed using RevMan 5.3. Methodological and statistical heterogeneity, as well as publication bias of the included studies, were assessed.

RESULTS

Four randomized controlled trials (266 LA versus 354 OA) and thirty-six case-controlled trials (2580 LA versus 3043 OA) were included in the analysis. Compared to OA, LA has a shorter length of stay, a lower rate of surgical site infection as well as a significantly lower overall complication rate. The rates of intraabdominal abscess formation, post-operative fever, pneumonia and ileus are similar in the two groups. So are the rates of readmissions and reoperations. LA was also shown to have a shorter time taken to oral intake and a lesser requirement of analgesics as well as intravenous antibiotics. Operative time for OA was found to be significantly shorter than that for LA.

CONCLUSION

This meta-analysis objectively demonstrates that laparoscopy has a better overall complication profile compared to OA and should be the procedure of choice in children with complicated appendicitis.

Laparoscopic versus open appendectomy in complicated appendicitis in children: a single center study

Background

Acute complicated appendicitis is a common abdominal emergency in children. Unlike simple appendicitis, laparoscopic appendectomy has not been considered yet the first choice in management of complicated appendicitis. This prospective randomized controlled clinical trial was conducted at Pediatric Surgery Department, Zagazig University Hospitals, Egypt, during the period from December 2018 to August 2019. The aim of the study was to evaluate the role of laparoscopic appendectomy in such cases compared to open appendectomy.

Results

Sixty patients were included in the study, divided randomly into 2 equal groups: laparoscopic and open appendectomy groups. The mean operative time was significantly longer with laparoscopic appendectomy than open appendectomy, 85 vs. 61 min, respectively (p < 0.001**). The time taken to start oral intake was significantly shorter with laparoscopic appendectomy than open appendectomy, 1.9 vs. 2.73 days, respectively (p = 0.025*). The mean hospital stay was significantly lower with laparoscopic appendectomy than open appendectomy, 4.23 vs. 5.13, respectively (p = 0.044*). There were no statistical differences between the two groups regarding wound infection, occurrence of postoperative ileus, intraperitoneal collection, or readmission.

Conclusions

Laparoscopic appendectomy is safe, feasible, and effective procedure in the management of complicated appendicitis in children, with no evidence of any increase in the postoperative complications.

The effect of laparoscopic and open surgery on oxidative DNA damage and IL-37 in children with acute appendicitis

BACKGROUND

Although laparoscopic appendectomy (LA) is considered to be minimally invasive compared with open appendectomy (OA), there are few studies showing this in terms of cytokines and oxidative stress markers.

AIM

LA and OA techniques have been compared in terms of different conditions such as operation time and complication rate. Here, we compared how oxidative DNA damage and some cytokines levels change in relation to LA and OA.

METHOD

This study was performed in children diagnosed with acute appendicitis in our hospital. The study was conducted on 30 children with acute appendicitis in each group. Oxidative DNA damage and malondialdehyde levels were determined by high-performance liquid chromatography, and interleukin-1β, interleukin-37, ischaemia-modified albumin and total thiol levels were determined by enzyme-linked immunosorbent assays.

RESULTS

There was a dramatic decrease in ischaemia-modified albumin (IMA) levels after LA. However, there were no statistically significant differences in pre- and postoperative IMA levels in the OA group. Oxidative DNA damage and malondialdehyde levels were low significantly according to preoperative levels after the LA and OA. Total thiol levels were high in children who underwent LA while they were low after OA. In addition, postoperative interleukin-1β levels were low in both groups. Furthermore, IL-37 levels postoperatively were low in the LA group, while there was no significant change in the OA group.

CONCLUSION

LA had a more positive effect on oxidative DNA damage, IL-1β and IL-37 than the OA. In addition, surgical stress was reduced with LA.

Management of paediatric acute appendicitis in the general hospital setting: a national survey of preferred surgical technique

BACKGROUND

The advent of laparoscopic surgery has facilitated the management of acute appendicitis in the adult population. In the paediatric population (<12 years), management varies according to institution and/or consultant expertise. The aim of this study was to analyse consultant preference for laparoscopic versus open appendicectomy in the management of acute appendicitis in children under 12 years presenting to general hospitals.

METHODS

A 15-point questionnaire was distributed to 81 consultant surgeons identified from the specialist register of the Irish Medical Council and practicing as general surgeons outside of specialist paediatric centres.

RESULTS

A response rate of 83 % (67/81) was obtained. Of the 67 surgeons surveyed, 11 (16 %) had formal paediatric training. Sixty percent (40/67) of surgeons expressed a preference for the open technique. The median frequency of on-call rota was >1 in 5 (32/67) and only 3 % (2/67) claimed that the on-call commitment influenced decision-making regarding surgical approach. The average minimum age (9.3 years, range 1-14) and average minimum weight (25 kg, range 12-70) at which the operating surgeon would perform a laparoscopic appendicectomy were also recorded. Thirty percent (20/67) of consultant general surgeons had immediate access to specialist paediatric laparoscopic equipment.

DISCUSSION

This study has shown wide variability amongst consultant general surgeons when considering open versus laparoscopic appendicectomy in children under 12 years. Restricted access to specialist paediatric laparoscopic equipment, combined with declining exposure to paediatric surgical training, may continue to limit the numbers of paediatric laparoscopic appendicectomies performed in the general setting.

Clinical results of laparoscopic appendectomy in patients with complicated and uncomplicated appendicitis

Acute appendicitis is the most common surgical emergency. The aim of this study was to evaluate the clinical results of laparoscopic appendectomy (LA) for the treatment of uncomplicated and complicated appendicitis. A retrospective analysis was performed who had undergone laparoscopic appendectomy for complicated appendicitis between January 2010 to October 2013. The diagnosis of acute appendicitis was established with physical examination, laboratory tests, and ultrasound examination. The patients were analysed for age, sex, conversion rate,operation time, postoperative infectious complications and length of hospital stay. A total of 452 patients were operated with LA. There were 362 (80.1%) uncomplicated (Group I) and 90 (19.1%) complicated Group (II) appendicitis.The intraabdominal abscess rate was 14.35% in Group I and 19.5% in Group II. The wound infection and rate of incisional hernia were also higher in Group II. The postoperative complications including intraabdominal abscess, wound infection and incisional hernia after LA in complicated appendicitis found high. LA should be performed very carefully in complicated appendicitis.

Laparoscopic approach to appendectomy reduces the incidence of short- and long-term post-operative bowel obstruction: systematic review and pooled analysis

BACKGROUND

The aim of this meta-analysis was to determine the effect of laparoscopic appendectomy (LA) compared to open appendectomy (OA) on short-term and long-term post-operative bowel obstruction.

METHODS

Medline, Embase, trial registries, conference proceedings and reference lists were searched. Subset analysis was performed for paediatric patients, patients who presented with perforated appendicitis and studies with long-term follow-up and surveillance for bowel obstruction and with surgery for bowel obstruction.

RESULTS

Overall, 29 studies comprising 159,729 patients (60,875 LA versus 98,854 OA) were included. LA was associated with a significant reduction in the incidence of post-operative bowel obstruction in the general population (pooled odds ratio (POR) = 0.43 [95 %C.I. 0.3-0.63]). Subset analysis demonstrated that LA significantly reduced the incidence of post-operative bowel obstruction in paediatric patients (POR = 0.48 [95 %C.I. 0.3-0.78]) and patients with perforated appendicitis (POR = 0.44 [95 %C.I. 0.26-0.74]). Furthermore, LA was associated with a significantly reduced incidence of long-term bowel obstruction (POR = 0.33 [95 %C.I. 0.19-0.56]) and bowel obstruction requiring surgery (POR = 0.31 [95 %C.I. 0.2-0.48]).

DISCUSSIONS

This present meta-analysis provides evidence to clearly demonstrate the benefits of a laparoscopic approach to appendectomy as reflected by a reduction in short- and long-term adhesive bowel obstruction. Important future areas for assessment include the influence of surgical approach on long-term quality of life following appendectomy.